AHIP AHM-540 Free Practice Questions

NEW QUESTION 1
Designing effective medical management programs for Medicare beneficiaries requires an understanding of the unique health needs of the Medicare population. One characteristic of Medicare beneficiaries is that they typically

• A. do not experience mental health problems
• B. consume more than half of all prescription drugs
• C. are likely to equate quality with the technical aspects of clinical procedures
• D. require longer and more costly recovery periods following acute illnesses or injuries than does the general population

Answer: D

NEW QUESTION 2
Health plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say
* 1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days
* 2. That the timeframe is accelerated for expedited appeals
* 3. That the review period begins when the appeal arrives at a health plan

• A. All of the above
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

Answer: D

NEW QUESTION 3
The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as

• A. generic substitution, and prescriber approval is not required
• B. generic substitution, and prescriber approval is always required
• C. therapeutic substitution, and prescriber approval is not required
• D. therapeutic substitution, and prescriber approval is always required

Answer: D

NEW QUESTION 4
Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

• A. Health plans rarely delegate HRA activities to external entities
• B. Health plans typically focus their HRA efforts on newly enrolled members
• C. HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members
• D. HRA is generally a reliable predictor of medical resource utilization

Answer: B

NEW QUESTION 5
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms you have chosen.
A primary distinction between skilled care and subacute care relates to the extent and medical complexity of the patient’s needs. Generally, subacute care patients require (more
/ fewer) services from physicians and nurses and (more / less) extensive rehabilitation services than do skilled care patients.

• A. more / more
• B. more / less
• C. fewer / more
• D. fewer / less

Answer: A

NEW QUESTION 6
This agency oversees fraud and abuse matters as they relate to medical management.

• A. Health Resources and Services Administration (HRSA)
• B. Office of Personnel Management (OPM)
• C. Department of Health and Human Services (HHS)
• D. Department of Justice (DOJ)

Answer: D

NEW QUESTION 7
The Glenway Health Plan’s pharmacy and therapeutics (P&T) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely

• A. cost-effectiveness analysis (CEA)
• B. cost-minimization analysis (CMA)
• C. cost-utility analysis (CUA)
• D. cost of illness analysis (COI)

Answer: A

NEW QUESTION 8
The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision.
• B. Disease management programs serve to improve both clinical and financial outcomes for healthcare services related to chronic conditions.
• C. Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management.
• D. Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

Answer: A

NEW QUESTION 9
The following statement(s) can correctly be made about the characteristics of peer review:
* 1.Peer review is applicable to either single episodes of care or to entire programs of care
* 2.Most peer review is conducted concurrently
* 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

• A. All of the above
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

Answer: C

NEW QUESTION 10
Determine whether the following statement is true or false:
Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.

• A. True
• B. False

Answer: A

NEW QUESTION 11
Determine whether the following statement is true or false:
The utilization review (UR) process produces the greatest number of case management referrals.

• A. True
• B. False

Answer: A

NEW QUESTION 12
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Ways that workers’ compensation health plans can help control the costs of job-related injuries and illnesses include

• A. applying strict definitions of medical necessity
• B. developing prevention and recovery programs
• C. applying out-of-network benefit reductions
• D. all of the above

Answer: B

NEW QUESTION 13
Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

• A. lack of qualified providers in provider networks
• B. lack of resources necessary to establish case management programs for patients with complex conditions
• C. unstable eligibility status of Medicaid recipients
• D. inability of Medicaid recipients to change health plans or PCPs

Answer: C

NEW QUESTION 14
The following statement(s) can correctly be made about performance measurement systems:
* 1.The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes
* 2.A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: C

NEW QUESTION 15
Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman’s condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation care unit. Transferring Ms. Newman to the observation care unit most likely

• A. resulted in unnecessarily expensive charges for treatment
• B. prevented M
• C. Newman from receiving immediate attention for her condition
• D. gave M
• E. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region
• F. allowed clinical staff an opportunity to determine whether M
• G. Newman required hospitalization without actually admitting her

Answer: D

NEW QUESTION 16
Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:
Provision 1—Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2—Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.

• A. Provision 1- ERISA Provision 2- HIPAA
• B. Provision 1- HIPAA Provision 2- ERISA
• C. Provision 1- BBA of 1997 Provision 2- HIPAA
• D. Provision 1- ERISA Provision 2- BBA of 1997

Answer: A

NEW QUESTION 17
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